Provider Demographics
NPI:1285676866
Name:GRAND MICHIGAN DENTISTRY, PC
Entity Type:Organization
Organization Name:GRAND MICHIGAN DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARPO GARZA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-527-4300
Mailing Address - Street 1:535 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3814
Mailing Address - Country:US
Mailing Address - Phone:312-527-4300
Mailing Address - Fax:312-527-4471
Practice Address - Street 1:535 N MICHIGAN AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3814
Practice Address - Country:US
Practice Address - Phone:312-527-4300
Practice Address - Fax:312-527-4471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTAX ID